Avril A. Farlam

The applicant sought statutory accident benefits following a motor vehicle accident.

The insurer denied two treatment plans on the basis that the injuries fell within the Minor Injury Guideline (MIG) and required the applicant to attend insurer's examinations under s. 44 of the Schedule.

The applicant refused to attend, arguing that s. 44 does not permit an examination to determine the applicability of the MIG.

The Licence Appeal Tribunal held that the insurer is entitled to request an examination to determine if the MIG applies, and that the applicant's legal interpretation was incorrect.

Because the applicant failed to attend the examinations without a reasonable explanation, he was barred from proceeding with his application under s. 55 of the Schedule.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits from the respondent insurer.

Following a reconsideration decision that removed the applicant from the Minor Injury Guideline, a rehearing was held to determine entitlement to disputed treatment plans and assessments.

The Tribunal found the applicant was entitled to three physiotherapy treatment plans and a psychological assessment, as the medical evidence, including reports from an orthopaedic surgeon and the respondent's own psychological assessor, established they were reasonable and necessary.

Claims for an attendant care assessment and a TMJ assessment were dismissed due to insufficient medical evidence linking the conditions to the accident or demonstrating necessity.

The applicant's request for a special award was denied as the respondent had not unreasonably withheld or delayed payments.

The applicant sought entitlement to various medical and rehabilitation benefits under the Statutory Accident Benefits Schedule following a motor vehicle accident, including a massaging bathtub, a lightweight vacuum cleaner, physiotherapy, massage therapy, and a BrainEx group therapy program.

The respondent denied the treatment plans on the basis that they were not reasonable and necessary.

The Tribunal dismissed the application, finding that the applicant failed to meet her burden of proof.

The Tribunal preferred the objective medical evidence of the respondent's assessors, noting that the applicant's ongoing symptoms were largely attributable to pre-existing conditions such as fibromyalgia and chronic migraines, and that the requested treatments were either excessive in cost, unsupported by medical evidence, or unnecessary given the applicant's medical history.

The applicant sought statutory accident benefits for injuries allegedly sustained in a 2011 motor vehicle accident.

The respondent denied the benefits, arguing the injuries fell within the Minor Injury Guideline (MIG) and that the requested treatments were not reasonable and necessary.

The Tribunal found that the applicant's injuries were predominantly minor and subject to the $3,500 MIG limit.

The Tribunal noted a significant gap in medical treatment following the accident and found that the applicant's subsequent workplace and gym accidents were more likely the cause of his ongoing complaints.

The application for medical benefits, cost of examinations, and other amounts was dismissed.

The applicant requested a reconsideration of a Tribunal decision that denied several treatment plans for chiropractic, psychological, orthopaedic, and chronic pain assessments.

The applicant argued the Tribunal violated procedural fairness by not allowing her to present evidence and made errors of law and fact regarding the Minor Injury Guideline and the reasonableness of the plans.

The Vice Chair dismissed the request, finding no violation of procedural fairness as the onus was on the applicant to prove her case, and no errors of law or fact in the original decision's assessment of the evidence.

The applicant was injured in a motor vehicle accident and sought medical benefits for three chiropractic treatment plans.

The respondent initially denied the plans, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and the plans were not reasonable and necessary.

At the hearing, the respondent conceded the MIG did not apply but maintained the plans were not reasonable and necessary.

The Tribunal found the treatment plans were reasonable and necessary, as the goals were reasonable, were being met to a reasonable degree, and the costs were reasonable.

The Tribunal ordered the respondent to pay for the treatment plans with interest, but denied the applicant's request for a special award, finding the respondent's initial denial was not unreasonable given its insurer examination report.

The applicants sought interest and a special award under the Statutory Accident Benefits Schedule, alleging the respondent insurer delayed payment of death and funeral benefits following the death of their child in a motor vehicle accident.

The Licence Appeal Tribunal dismissed the claims, finding that the initial application for benefits was incomplete because it lacked essential eligibility documentation.

The insurer paid the benefits within 30 days of receiving the completed application, meaning the payment was never overdue and no interest or special award was payable.

The applicant was injured in a motorcycle accident and sought medical benefits for two treatment plans proposing chiropractic and massage therapy.

The respondent insurer denied the plans, arguing they were not reasonable and necessary based on insurer examinations.

The Tribunal found the applicant's family physician and treating clinic records established the treatments were reasonable and necessary, noting the applicant's condition deteriorated when therapy stopped.

The Tribunal ordered the respondent to pay for both treatment plans with interest.

The applicant sought statutory accident benefits following a motor vehicle accident.

The respondent denied a treatment plan for physiotherapy, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 funding limit had been exhausted.

The Tribunal found that the applicant's physical injuries were predominantly minor and that she failed to provide sufficient medical evidence to establish a psychological impairment or chronic pain that would remove her from the MIG.

As the funding limit was already expended, the Tribunal dismissed the claim for the disputed treatment plan and interest.

The applicant was struck by a vehicle as a pedestrian and sought statutory accident benefits.

The respondent denied several treatment plans and assessments on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 funding limit had been exhausted.

The Tribunal found that the applicant's physical injuries were predominantly minor (sprains and strains) and that he failed to provide compelling medical evidence of a pre-existing condition, psychological impairment, or chronic pain caused by the accident that would remove him from the MIG.

As the MIG limit was exhausted, the disputed treatment plans were not payable, and claims for interest and a special award were dismissed.

The applicant sought income replacement benefits (IRB) following a 2013 motor vehicle accident.

The respondent insurer denied the IRB claim in May 2014 after the applicant returned to work.

The applicant stopped working again in 2016 but did not dispute the IRB denial until filing a Tribunal application in March 2019, well beyond the two-year limitation period under s. 56 of the Statutory Accident Benefits Schedule.

The Tribunal found the application was statute-barred and declined to extend the limitation period under s. 7 of the Licence Appeal Tribunal Act, 1999, noting the lack of a bona fide intention to appeal within the time limit, the excessive 34-month delay, prejudice to the respondent, and lack of merit.

The applicant sought statutory accident benefits following a motor vehicle accident.

The respondent denied the benefits and requested a preliminary issue hearing to determine if the applicant was barred from proceeding due to her failure to attend multiple insurer's examinations under s. 44 of the Schedule.

The Tribunal found that the respondent provided proper notice and the applicant failed to provide a reasonable explanation for missing six scheduled examinations.

Consequently, the applicant was barred from proceeding under s. 55 of the Schedule, and the application was dismissed.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits.

The insurer denied the claim for non-earner benefits and income replacement benefits in a clear and unequivocal explanation of benefits.

The applicant filed an application with the Licence Appeal Tribunal regarding income replacement benefits only, but later sought to change the issue to non-earner benefits after the two-year limitation period had expired.

The Tribunal found the application for non-earner benefits was statute-barred under s. 56 of the Statutory Accident Benefits Schedule.

The Tribunal declined to extend the limitation period under s. 7 of the Licence Appeal Tribunal Act, finding no bona fide intention to appeal within the time limit, excessive delay, prejudice to the insurer, and lack of merit to the claim.

The application was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident.

The respondent denied two chiropractic treatment plans on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the treatment was not reasonable and necessary.

The Tribunal found that the applicant's injuries were predominantly minor and that he had not established a pre-existing condition or chronic pain that would remove him from the MIG.

The Tribunal also found that the treatment plans were not reasonable and necessary.

Although the respondent failed to comply with the notice requirements under s. 38(8) of the Schedule for a brief period, no treatment costs were incurred during that time.

The application was dismissed.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits.

The respondent insurer determined the injuries fell within the Minor Injury Guideline (MIG) and denied several treatment plans.

The Tribunal found that the applicant's physical and psychological injuries were predominantly minor and did not warrant removal from the MIG.

Two of the disputed treatment plans were found to be statute-barred as the application was commenced more than two years after the insurer's refusal.

The remaining chiropractic treatment plans were allowed subject to the MIG limits, while the claims for an in-home assessment and psychological assessment were denied.

The applicant sought income replacement benefits (IRBs) following a motor vehicle accident, claiming a substantial inability to perform the essential tasks of his pre-accident employment as a gas station cashier.

The respondent insurer denied the benefits.

The Licence Appeal Tribunal found that the medical evidence, including reports from the applicant's physicians and occupational therapists, did not support a finding of substantial inability to work.

The applicant's claim for IRBs, interest, and a special award was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident.

The respondent denied certain treatment plans, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 funding limit had been exhausted.

The applicant argued that psychological impairments, insomnia, and chronic pain removed him from the MIG.

The Tribunal found that the applicant's physical injuries were soft tissue injuries falling within the MIG definition.

The Tribunal concluded the applicant failed to provide sufficient evidence that his insomnia or chronic pain were caused by the accident.

As the injuries were predominantly minor, the disputed treatment plans and examination costs were not payable.

The application was dismissed.

The applicant sought income replacement benefits (IRBs) and the cost of prescription medications following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the claim for IRBs because the applicant failed to file a 2016 income tax return, meaning his pre-accident income was deemed to be nil under section 4(5) of the Statutory Accident Benefits Schedule.

The claim for prescription medications was also dismissed as the respondent had already paid the amount.

No interest was payable.

The applicant sought statutory accident benefits following a rear-end motor vehicle collision.

The respondent denied a chiropractic treatment plan on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 funding limit had been reached.

The applicant argued that pre-existing disc bulges and chronic back pain prevented maximal recovery within the MIG limits.

The Tribunal found that the applicant failed to provide compelling medical evidence of a pre-existing condition that would remove her from the MIG.

As the injuries were predominantly minor, the treatment plan was not payable, and claims for interest and a special award were dismissed.

The applicant sought death and funeral benefits from the respondent insurer after her spouse died from smoke inhalation in his motor vehicle.

The fire investigation report concluded the fire was intentionally set by the deceased using a cigarette lighter, a dishtowel, and gasoline.

The Tribunal applied the two-part test for an 'accident' under section 3 of the Statutory Accident Benefits Schedule.

The Tribunal found that the incident did not meet the purpose test, as the vehicle was used as a venue and mechanism for suicide, which is an aberrant use.

Furthermore, the incident did not meet the causation test, as the intentional setting of the fire was an independent intervening act that broke the chain of causation.

The application was dismissed.